QAPI Committee Lacked Required Membership and Participation
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) group had the required members and met at least quarterly, as mandated by policy. Interviews with staff revealed that only a limited number of staff members, specifically staff member A, staff member B, and occasionally staff member G, attended the QAPI meetings. Staff member G, who was only onsite once a month, did not attend meetings in person and was only informed of the meeting outcomes after the fact via phone call. There was no documentation to confirm that staff member C attended any meetings by phone, and staff member A acknowledged that additional required members had not been invited to participate in the QAPI meetings. Review of QAPI meeting minutes and attendance sheets confirmed that the required interdisciplinary team composition was not met, with only a few staff members present and no evidence of the Medical Director or designee's participation. The facility's own QAPI policy specified that the committee must include the Director of Nursing Services, the Medical Director or designee, and at least three other staff members, including the administrator. The lack of appropriate committee membership and participation had the potential to affect all residents receiving care in the facility.